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The U.S. House of Representatives leadership’s bill to repeal and replace the Affordable Care Act (ACA) would have significantly expanded the use of health savings accounts (HSAs), which people can use to save tax-free money to pay for certain medical expenses. This effort isn’t new and it’s not likely to go away just because a vote on the House bill, the American Health Care Act (AHCA), has been tabled. Amendments to the tax code to encourage HSAs have been a staple of Republican health care proposals, and the HSA provisions in the House legislation were introduced as a standalone bill last year.

The U.S. House of Representatives leadership’s bill to repeal and replace the Affordable Care Act (ACA) would have significantly expanded the use of health savings accounts (HSAs), which people can use to save tax-free money to pay for certain medical expenses. This effort isn’t new and it’s not likely to go away just because a vote on the House bill, the American Health Care Act (AHCA), has been tabled. Amendments to the tax code to encourage HSAs have been a staple of Republican health care proposals, and the HSA provisions in the House legislation were introduced as a standalone bill last year.

Why all the interest? HSA proponents suggest the accounts offer cost savings and give consumers freedom to spend their money how they see fit. An HSA must be paired with a high-deductible health plan (HDHP), and there is evidence that the combination of an HDHP and HSA does reduce health care spending—by leading consumers to skip care, both needed and unneeded. Yet there is little basis to conclude that HSAs expand access to care, or that the tax benefits these accounts promise reach most Americans. In practice, most financial advantages have accrued to the top 5 percent of earners, who can afford to contribute to the accounts during the year and reap larger gains at tax time.

HSAs: The Basics

HSAs were created in 2003 in legislation establishing a Medicare prescription drug benefit. They are tax-preferred savings accounts funded by consumers and sometimes their employers. Consumers can contribute to an HSA only if they are enrolled in an HDHP, which in 2017 is an individual or group health plan that has a deductible of at least $1,300 ($2,600 for a family plan). Unlike other savings vehicles established under federal law, HSAs provide what amounts to triple tax benefits: contributions are tax-deductible; account funds are invested and grow tax-free; and withdrawals are tax-exempt (if they are used for qualified medical expenses).

HSAs are far more attractive to higher-income individuals, who are more likely to have sufficient income to fund the accounts and gain a greater tax benefit than are lower-income individuals subject to lower tax rates. In 2013, tax filers with income above $200,000 were 10 times more likely to claim a tax deduction for HSA contributions than those with incomes below $50,000, and the tax-advantaged contributions these high earners made were, on average, more than twice as large. A study of HSA take-up in the group market from 2005 to 2012 found similar results and observed, perhaps unsurprisingly, that high-income households were substantially more likely to fund their HSAs fully (with their own dollars and contributions from employers) than were middle- and lower-income filers.

Enhanced HSAs on the Horizon?

The AHCA would have expanded use of HSAs by authorizing higher tax-free contributions (increasing the amount from $3,400 to $6,550 for an individual plan) and more tax-free uses for funds. The AHCA also would have cut in half the penalty for withdrawals for nonmedical expenses.

Other proposals would provide similar and sometimes greater benefits to account holders. Legislation previously authored by Health and Human Services Secretary Tom Price would increase HSA contribution limits while also making it easier to shelter those funds and other retirement savings from taxes when they are transferred to heirs. Senator Rand Paul’s (R–Ky.) ACA replacement bill would go still further, erasing the requirement that HSAs be linked to a high-deductible plan and eliminating contribution limits altogether.

There is little doubt these expansions would encourage HSA take-up. Likewise, the proposals would make HSAs even more attractive as savings and estate planning vehicles for high-income households—particularly those who earn too much to contribute to other tax-advantaged retirement accounts and those who have maxed out such contributions. At the same time, the financial services companies that manage these accounts would reap substantial benefits, too.

Looking Ahead

HSAs are already growing under current law: by 2017, nearly 21 million accounts held more than $41 billion in assets, while the cost of the program to taxpayers has steadily increased and will nearly double by 2020. The AHCA would have dramatically accelerated this trend, causing federal spending to shoot up nearly 50 percent over the first three years following enactment and by a total of more than $19 billion by 2026.

The Congressional Budget Office estimated that the AHCA would have reduced insurance coverage dramatically, especially among Americans with low incomes. Moreover, the people most likely to need assistance paying for coverage and out-of-pocket costs—those with incomes under 200 percent of poverty, or around $24,000 for a single person—are the least likely to benefit from the bill’s approach to making coverage more affordable: HSAs. Given an ACA replacement’s potential impact on federal spending and coverage, spending billions of dollars on a program that primarily helps those least likely to need assistance purchasing coverage and paying out-of-pocket costs warrants scrutiny.

A study of one of the nation’s largest Medicare accountable care organizations (ACOs) found that participating physicians see a relatively small number of patients who are actually part of the ACO population: less than 5 percent of a typical patient panel consists of ACO patients. The ACO also experiences substantial physician turnover. And when physicians leave the ACO, most of their attributed beneficiaries leave as well.

The Issue

“Physicians play a central role in the delivery of medical care and, not surprisingly, also are critical players in Medicare payment reform.”

To increase provider accountability for the cost and quality of patient care, health care systems, including the Medicare and Medicaid programs, have begun to move away from fee-for-service and toward ACOs and other alternative payment models that encourage more efficient and effective care delivery. With the ongoing implementation of the Medicare Access and CHIP Reauthorization Act of 2015, the numbers of physicians and provider organizations entering alternative payment models such as ACOs is likely to accelerate rapidly. Evidence to date, however, indicates that ACOs have achieved limited success in attaining their goals. Even though physicians play a decisive role in whether ACOs are able to deliver on their promise, there has been limited research on the physicians who work in ACOs and their experiences with patients. Commonwealth Fund–supported researchers studied a large Medicare Pioneer ACO to learn about the stability of physician participation and beneficiary enrollment.

Key Findings

The ACO experienced substantial turnover among physicians: only 52 percent were affiliated over the entire three-year contract period.

Most (88%) physicians had at least some beneficiaries attributed to them, but these patients accounted for just a small part of their panels, which averaged 1,700 patients per panel. Half (50%) of physicians had just 70 or fewer attributed beneficiaries. ACO enrollees accounted for less than 5 percent of the median physician’s patient panel.

About half (49%) of beneficiaries who joined the ACO in contract year 2 or 3 did so because their physician had joined the ACO. When physicians left the ACO in year 2 or 3, 90 percent of their assigned beneficiaries also left.

The Big Picture

The study’s findings suggest that two factors can dampen an ACO’s potential to hit its financial targets: a relatively low number of enrollees attributed to participating physicians, and the loss of patients when physicians leave the ACO. To the extent that there is patient turnover, the ACO’s incentives also are dampened with respect to investments that require more than a few months to achieve any payoff. The authors conclude that the financial incentives provided by ACOs to provide better, more efficient care may not be sufficient to attract physicians, given the small numbers of ACO beneficiaries they tend to serve. Physicians, they say, might instead repond better to comparable incentives that are linked to having a larger number of patients on their panels. This, however, would require standardizing incentives across payers. Standardization also reduces the potential cacophony associated with having a large number of incentives. Health systems also could reconsider how they link beneficiaries to primary care physicians to concentrate care among a smaller number of physicians, creating a critical mass of patients that might encourage and facilitate practice pattern changes.

The authors also note that having the ability to select participating physicians each year creates a temptation for ACOs to improve their risk profile—and thereby increase their opportunity for shared savings—by dropping the small number of physicians whose patients have the most unfavorable risk mix (e.g., those with very high treatment costs). The Centers for Medicare and Medicaid Services could put policies in place that would reduce the incentive to game the risk pool.

About the Study

The researchers used the following data sources for their analysis: a list of beneficiaries aligned to Partners HealthCare’s ACO; a list of physicians affiliated with the ACO during that period; databases that captured the number of years a physician was affiliated with the ACO, physician specialty, and other factors; and Medicare claims data.

The Bottom Line

A low number of attributed enrollees per physician and substantial physician turnover may help explain the muted impact that accountable care organizations have had thus far.

It opened for signature a decade ago. It’s time for the U.S. Senate to act.

On a Friday afternoon in July 2009, President Obama gave remarks in the East Room of the White House about the signing of an international human rights treaty to protect the rights of people with disabilities.

“Disability rights aren’t just civil rights to be enforced here at home; they’re universal rights to be recognized and promoted around the world,” Obama said. “And that’s why I’m proud to announce that next week, the United States of America will join 140 other nations in signing the United Nations Convention on the Rights of Persons with Disabilities, the first new human rights convention of the 21st century.”

The treaty, known as CRPD, was inspired by U.S. leadership on disability rights and is modeled after the Americans with Disabilities Act (ADA) of 1990, which protects individuals with disabilities against discrimination in areas such as employment, public accommodations, and transportation.

“This extraordinary treaty calls on all nations to guarantee rights like those afforded under the ADA. It urges equal protection and equal benefits before the law for all citizens; reaffirms the inherent dignity and worth and independence of all persons with disabilities worldwide,” Obama said.

CRPD opened for signature 10 years ago today — and as the committee that monitors CRPD implementation meets in Geneva right now to consider reports from eight countries, it’s a good reminder that the United States isn’t one of them. Despite Obama’s signature nearly eight years ago, the treaty — ratified by 172 countries — still awaits U.S. Senate ratification.

In December 2012, a Senate vote (61–38) fell five votes short of the two-thirds majority required to adopt an international treaty. In July 2014, the Senate Foreign Relations Committee advanced the treaty(12–6) — but the full Senate never took a vote.

But ratifying CRPD represents an opportunity to take bipartisan action and stand with the rest of the world in advancing the civil and human rights of people with disabilities everywhere. And it’s an opportunity to continue our nation’s tradition of advancing important human rights protections, as we did with the Rehabilitation Act, the Individuals with Disabilities Education Act, the ADA, and the ADA Amendments Act of 2008 — all signed by Republican presidents.

Disability rights are civil and human rights. Now, a decade after the treaty opened for signature, it’s time to finally make a global commitment to protecting disability rights by ratifying it.

Abstract

Background

The prevalence of obesity is higher in those with intellectual disabilities than the general population. The aim of the study was to understand the determinants of physical activity and dietary patterns in this population during their final year of school.

Results

Adolescents’ environment and social interactions play a pivotal role in influencing physical activity and dietary patterns. Three themes emerged from the analysis: situatedness, motivation and wider environmental influences.

Conclusions

School structure, high self-efficacy and social connectedness facilitate increased physical activity and healthier diet in adolescents with intellectual disabilities. Home life, low self-efficacy and a lack of social connectedness can serve as a barrier to PA and a healthy diet.

Abstract

Background

Providing long-term care to an adult relative with intellectual disability can impact negatively on caregivers’ health and well-being.

Methods

Data were collected via online and postal questionnaires on 110 family carers’ physical and psychological health, family stress and perceived positive gains from caring. Psychological adaptation and carers’ satisfaction with available support were also examined.

Results

Study participants reported more health problems than general populations. Higher support needs of care recipients were associated with increased family stress. Carers being female were associated with lower family stress. Older age and better socio-economic position were associated with better psychological outcomes. Other associations were consistent with psychological adaption and perceived helpfulness of support buffering negative outcomes and facilitating positive gains from caring.

Conclusions

Family carers of adults with intellectual disability appear to experience poorer health outcome than population norms. Adaption to the caregiving role may buffer negative outcomes. Further large scale, population-based, longitudinal research is needed.

Abstract

Background

This study sought to identify, from the perspective of people with intellectual disabilities and life limiting conditions, the factors that strengthened and inhibited their Advance Care Planning.

Methods

This in depth qualitative study explored the experiences of four people with intellectual disability and life limiting conditions, through interviews and documentation reviews.

Results

There was strong agreement across all participants about what positively influenced Advance Care Planning, namely; going at my pace; supporting me to make my own choices; adapting the process to suit me, and, most importantly; continuing to support and plan the life I’m still living. With the exception of being comfortable/skilled in end-of-life support, the skills required of facilitators were similar to those required for all forms of person-centred planning.

Conclusion

The findings are encouraging and demonstrate that Advance Care Planning is a useful tool in ensuring that people with intellectual disability have control and choice over their lives, right to the end.

Employees of qualifying companies – those that self-identified as being in the healthcare industry ― answered 58 questions about how often they experience the behaviors that make a workplace great, such as whether they feel physically safe, whether they are proud to work there, and whether employees care about each other.

The Top Five

Topping the list of 30 again this year was Texas Health Resources, headquartered in Arlington, with 18,815 employees. Of 1256 employees surveyed, 94% said their workplace was great. It was also ranked 31 this year in Fortune’s 100 Best Companies to Work For.

The company cited programs and policies that showcase what makes it unique. Among them are low medical premiums with low deductibles and 90% coinsurance and a 401k matching program in which, after 1 year, the company matches every dollar an employee contributes, up to certain limits. Also, Texas Health pays for tuition and some fees for approved degree plans that benefit the employee or the company.

Coverage: Studies show that Medicaid expansion results in significant coverage gains and reductions in uninsured rates, both among the low-income population broadly and within specific vulnerable populations.

Access to care, utilization, affordability, and health outcomes: Most research demonstrates that Medicaid expansion positively impacts access to care, utilization of services, the affordability of care, and financial security among the low-income population. Studies have also shown improved self-reported health following expansion, but additional research is needed to determine effects on health outcomes.

Economic measures: Analyses find positive effects of expansion on multiple economic outcomes, despite Medicaid enrollment growth initially exceeding projections in many states. Studies also show that Medicaid expansions result in reductions in uncompensated care costs for hospitals and clinics as well as positive or neutral effects on employment and the labor market.

As the Trump Administration and Congress debate ACA repeal and replacement, gains in coverage and access as well as economic benefits to states and providers are at stake if the Medicaid expansion is repealed.

Research on the effects of Medicaid expansions under the Affordable Care Act (ACA) can help increase understanding of how the ACA has impacted coverage; access to care, utilization, affordability, and health outcomes; and various economic outcomes, including state budgets, the payer mix for hospitals and clinics, and the employment and labor market. Understanding these findings can help inform the debate over a repeal of the ACA (which would include the Medicaid expansion).

This summary reviews findings from 108 studies of the impact of state Medicaid expansions under the ACA published between January 2014 (when the coverage provisions of the ACA went into effect) and January 2017. (This is an update to an earlier issue brief, “The Effects of Medicaid Expansion under the ACA: Findings from a Literature Review,” that covered studies published through May 2016.) It includes peer-reviewed studies as well as free-standing reports, government reports, and white papers published by research and policy organizations, using data from 2014 or later. This brief only includes studies that examine impacts of the Medicaid expansion; it excludes studies on impacts of ACA coverage expansions generally (not specific to Medicaid expansion alone) and studies investigating potential effects of expansion in states that have not (or had not, at the time of the study) expanded Medicaid. In both the brief below and the tables, findings are separated into three broad categories: Medicaid expansion’s impact on coverage; access to care, utilization, affordability, and health outcomes; and economic outcomes for the expansion states.